Posterior reversible encephalopathy syndrome (PRES) is characterized by rapid onset of symptoms including headache, seizures, altered consciousness, and visual disturbance, as well as radiologic findings of focal reversible vasogenic edema. Multiple visual disturbances have been described in PRES, such as hemianopia, visual neglect, auras, visual hallucinations, and cortical blindness. However, horizontal gaze palsy has not been previously reported. We report a 72-year-old female who presented with blurred vision, severe headache, lethargy, and later developed seizures. She was found to have left horizontal gaze palsy with intact vestibulo-ocular reflex. Brain magnetic resonance imaging (MRI) showed severe edema throughout the subcortical white matter, and signal in the posterior parietal and occipital lobes. She was diagnosed with PRES associated with supranuclear gaze palsy.
Case presentationA 72-year-old female presented to the emergency department with a one-day history of recurrent falls and lethargy. She attributed her falls to tripping on things she didn't see. Her complaints were associated with constant, severe headache that was unresponsive to analgesia. No other significant symptoms were reported. She had a past medical history of coronary artery disease, peripheral artery disease, hypertension, and dyslipidemia.Her vital signs showed a blood pressure of 230/80 mmHg, heart rate 76/min, oxygen saturation of 99%, and temperature of 97.4. On examination, she was confused with slowed responses and oriented only to person. She had impaired remote memory and concentration. Her neurological examination was significant for left horizontal gaze palsy with intact vestibulo-ocular reflex, and right lower limb weakness with brisk right lower limb reflexes. No other focal neurological deficits were seen. The rest of her examination was unremarkable.Blood workup including blood count, electrolytes, renal function, thyroid function, and rheumatological markers were insignificant. Brain computed tomography (CT) scan didn't show any acute pathology. The blood pressure was slowly lowered in the emergency department, and she was admitted for further workup and evaluation.On the night of her admission, the patient developed a simple partial seizure with left upper limb tonic-clonic movements. Three doses of lorazepam, and fosphenytoin failed to control the seizures, which lasted for more than 20 minutes, and the patient required intubation. Repeat brain CT scan showed low density in the subcortical white matter in the parietal and occipital lobes (Figure 1). Subsequent magnetic resonance imaging (MRI) of the brain showed severe edema throughout the subcortical white matter, and increased signal in the posterior parietal and occipital lobes with lesser involvement of the frontal lobes and lateral temporal lobes (Figure 2).She was successfully extubated on the following day. During her hospital stay, the lateral gaze resolved and her mental status continued to improve. Follow up head CT scan showed near complete...